How I decide whether you need an operation
I do not operate on every patient who walks in with piles, a fistula, a fissure, a hernia or varicose veins. After 19+ years and 6,000+ Surgeries, the most useful thing I can give you at a first visit is a clear answer to one question: does this actually need an operation? Here is how I decide, condition by condition.
Each table follows a published surgical guideline. Which row applies to you is decided after I examine you, and after imaging where I say so. It is a guide, not a diagnosis. Results vary. The hospital publishes the full version as the hospital's written operating criteria.
Dr. Kundan Kharde · MBBS · MS (General Surgery), FMAS · 4.9 ★ · 140+ Google reviews
When do I advise against surgery for piles?
For most Grade 1 and Grade 2 piles. Diet, medicines and, if bleeding continues, an office procedure such as banding or sclerotherapy usually come first. Grade 3 and Grade 4 piles usually need day-care surgery. I grade the piles on examination, not from symptoms alone. Results vary.
| What I find | What I usually do | Why |
|---|---|---|
| Grade 1–2 | Diet, medicines; office procedure if bleeding persists | ASCRS 2018: fibre first; office procedures for Grade 1–2 failing medical care |
| Grade 3 | Usually day-care surgery; banding for selected smaller piles | ASCRS 2018: surgery when office treatment fails or is unsuitable |
| Grade 4 or large external component | Day-care surgery | ASCRS 2018: excisional or stapled surgery for advanced piles |
More: Piles treatment
Does every fistula need an operation?
Most established fistulas do, because the tract rarely closes on its own. What I will not do is operate on a tract I have not mapped. I image almost every fistula before I operate — MRI fistulogram or trans-rectal ultrasound — and the tract decides the operation. An acute abscess is drained first; a Crohn's-related fistula is controlled medically, with a gastroenterologist, before definitive surgery. Results vary.
| What I find | What I usually do | Why |
|---|---|---|
| Early, simple, superficial tract | I do a fistulotomy (lay-open) | Almost no sphincter muscle is involved, so continence is not at risk |
| Mature, fibrosed superficial tract | I do a fistulectomy | Removes the whole hardened tract rather than only opening it |
| Deep tract involving more than 50% of the external sphincter | Combination technique — proximal fistulotomy + distal core-out, with seton or laser (FiLaC) as required | Clears the tract while protecting continence |
| Recurrent, multiple or horseshoe tracts | I treat it in stages — seton first, then the definitive procedure | Imaging has shown every branch; staging clears them without cutting sphincter twice |
More: Fistula treatment in Pune · can a fistula heal without surgery?
When does a fissure not need surgery?
Most acute fissures — under about eight weeks — heal with fibre, fluids, sitz baths and an ointment. A chronic fissure still gets a course of GTN or diltiazem first. I offer Botox or lateral internal sphincterotomy only when a chronic fissure has not healed on medical treatment. Results vary.
| What I find | What I usually do | Why |
|---|---|---|
| Acute fissure (under ~8 weeks) | Fibre, fluids, sitz baths, ointment | ASCRS 2023: non-operative care first |
| Chronic fissure, not yet treated | Topical GTN or diltiazem course | ASCRS 2023: first-line for chronic fissure |
| Chronic fissure failing medical treatment | Botox or LIS, chosen with you | ASCRS 2023: after medical therapy fails |
More: Fissure treatment
When do I watch a hernia instead of repairing it?
A hernia will not close by itself, but a small inguinal hernia in a man that causes no or minimal symptoms can be watched safely with review. I advise repair when it hurts, limits you or grows — and for any femoral hernia. Results vary.
| What I find | What I usually do | Why |
|---|---|---|
| Man, inguinal hernia, no or minimal symptoms | Watchful waiting with review | HerniaSurge 2018: acceptable option |
| Painful, limiting or enlarging hernia | Planned repair | HerniaSurge 2018 |
| Femoral hernia, or groin hernia in a woman | Prompt repair | HerniaSurge 2018: higher strangulation risk |
More: Hernia surgery
When do varicose veins not need EVLT?
Spider and reticular veins without symptoms (CEAP C1) do not need EVLT. I consider EVLT for symptomatic veins when a duplex ultrasound confirms reflux in a main vein, or when there are skin changes or an ulcer. Results vary.
| What I find | What I usually do | Why |
|---|---|---|
| Spider or reticular veins, no symptoms | No EVLT; advice, sclerotherapy only for appearance if you want it | NICE CG168: cosmetic, not an ablation indication |
| Symptomatic veins, truncal reflux on duplex | EVLT considered | NICE CG168: endothermal ablation first-line |
| Skin changes, ulcer or bleeding vein | Treatment prioritised | NICE CG168: referral indications |
More: Varicose veins treatment
Do I operate on silent gallstones?
Usually not. Stones found by chance, with no symptoms and a normal gallbladder and bile duct, generally need no treatment — I tell you what symptoms to come back for. I advise surgery for biliary colic, cholecystitis, gallstone pancreatitis or bile-duct stones. Results vary.
| What I find | What I usually do | Why |
|---|---|---|
| Incidental stones, no symptoms | No operation; symptom list to watch | NICE CG188: no treatment unless symptoms develop |
| Biliary colic or cholecystitis | Laparoscopic cholecystectomy | NICE CG188 |
| Pancreatitis or bile-duct stones | Duct clearance and cholecystectomy | NICE CG188 |
When does a pilonidal sinus not need surgery?
When it causes no trouble. A pit with no pain, discharge or abscess needs hygiene, hair control and review — not an operation. An abscess is drained first; I plan surgery for recurrent abscess or persistent discharge. Results vary.
| What I find | What I usually do | Why |
|---|---|---|
| Pit only, no symptoms | Hygiene, hair control, review | ASCRS 2019: no surgery for asymptomatic disease |
| Acute abscess | Drainage first | ASCRS 2019 |
| Recurrent abscess or persistent discharge | Planned laser or excision surgery | ASCRS 2019 |
What do you leave with if I don't operate?
A written plan: findings, medicines, a diet sheet, a review date and a clear “come back sooner if…” list. Second-opinion patients are welcome to bring outside reports and MRI scans.
Frequently asked questions
Will you push me into surgery at the first visit?
Can I come to you for a second opinion?
Do you image every fistula before operating?
Who makes the final decision?
Not sure you need an operation? Ask me first.
Written and reviewed by Dr. Kundan Kharde, MBBS · MS (General Surgery), FMAS. Published 25 September 2026.